RU2286098C1 - Method for heterotopic plasty of bladder - Google Patents

Abstract

FIELD: medicine, urology.

SUBSTANCE: the present innovation should be applied in situations after removing patient's bladder. It is necessary to mobilize ileum at the distance of about 55-60 cm leaving 20 cm against ileocecal angle, form an interintestinal anastomosis followed by detubularization of 50 cm of transplant's part to rotate it for the angle of 180 deg. around mesentery so, that detubularized part should be located towards right-hand ileal area. Detubularized part should be at first subjected to longitudinal and then - transverse reconfiguration by, thus, forming a low-pressure reservoir. Ureters should be anastomosed with reservoir along its posterior wall upon modeling catheters according to special technique. The rest transplant's part should be narrowed due to applying Lembert suture at the distance of 0.5 cm against each other. The first row of sutures should be covered with uninterrupted blanket suture with the same ligature, after that, modeling catheters and the tube developed for urinary removal should be withdrawn through separate incisions of anterior abdominal wall. On forming the stoma the site of catheters output should be limited against abdominal cavity with several sutures between reservoir's anterior wall and parietal peritoneum of anterior abdominal wall. The innovation enables to obtain controlled urinary removal through the stoma, increase the capacity of patient's bladder under development, decrease its intraluminal pressure and exclude complications caused by constant urinary suffusion.

EFFECT: higher efficiency of plasty.

14 dwg, 1 ex, 1 tbl

Description

The invention relates to medicine, urology and can be used in situations after removal of the bladder.

Known methods for plastic surgery of the bladder by forming it from the ileum and transverse colon (1, 2, 3, 4, 5, 6).

Closest to the proposed method for technical implementation is the method of heterotopic bladder plasty, including the formation of ureteroileocutaneostomy (Bricker operation), (7) performed after radical cystectomy, by cutting out an ileum fragment of 18-20 cm in size, while the gastrointestinal tract is restored the formation of enteroenteroanastomosis, the mobilized fragment is located in the abdominal cavity in the isoperistaltic direction, the ureters are anastomosed with ransplantatom by Nesbit method, the proximal end of the graft is sutured tightly dual inline seam, the distal end of the graft is derived through a separate incision in the anterior abdominal wall right iliac region where the stoma is formed that rises above the skin for ease of use of the urinal. The main disadvantages of this method of plastics are:

- uncontrolled excretion of urine through the stoma;

- the existing fragment of the intestine is practically deprived of capacity due to its constant peristaltic contraction;

- due to the high intraluminal pressure, excretory function of the kidneys, frequent inflammatory complications in the kidneys suffer;

- due to the constant leakage of urine, parastomal dermatitis is frequent, and the desire of patients to obstruct the stoma to reduce leakage of urine leads to the formation of urinary fistulas.

A new technical task is to reduce complications and improve the quality of life of patients.

The problem is solved by a new method of heterotopic intestinal plasty of the bladder, including radical cystectomy and lymphadenectomy, mobilization of the ileum, followed by the formation of the urinary reservoir from it, urine removal mechanism and modeling of the cutaneous stoma, and the ileum is mobilized for the formation of the urinary reservoir for 55-60 cm , retreating 20 cm from the ileocecal angle, form an inter-intestinal anastomosis, then detubularize 50 cm of the transplant site, rotate it 180 ° around the mesentery so that the detubularized area is located towards the right iliac region, then the detubularized section is first subjected to longitudinal and then transverse reconfiguration, forming a reservoir of low pressure, the ureters anastomose with the reservoir along its posterior wall on modeling catheters according to the Nesbit method , the remainder of the graft is narrowed by suturing a Lambert suture at a distance of 0.5 cm from each other, after which modeling catheters and a somnified tube for urinary diversion fed through a separate incision of abdominal wall, after the formation of the stoma exit site of the catheter delimit abdomen several seams between the front wall of the tank and the parietal peritoneum of the anterior abdominal wall.

The method is as follows. The operation is performed under ETN. Median laparotomy, perform a typical radical cystectomy and lymphadenectomy on both sides. Mobilization of 55-60 cm of the terminal ileum is performed, retreating 20 cm from the ileocecal angle (Figure 1). With a sufficient length of the mesentery, as a rule, it is enough to cross the artery of the arcade closest to the intestinal wall, while the parietal mobilization of the mesentery is not more than 3 cm along the intestinal wall for subsequent application of an inter-intestinal anastomosis. Delineation of the free abdominal cavity from the ingestion of intestinal contents with 4 gauze napkins. Cross the intestinal wall at a right angle with preliminary ligation of the vessels of the submucosal layer. Patency of the gastrointestinal tract is restored by applying an inter-intestinal anastomosis between the proximal and distal ends of the intestine - end to end with a two-row nodal suture according to Czerny so that the formed anastomosis is above the mesentery of the mobilized intestinal transplant. The proximal end of the graft is clamped with a soft clip and a silicone probe is inserted into the intestinal lumen, through which a warm 3% solution of boric acid is injected to remove intestinal contents. After that, release the proximal end of the graft from the clamp and straighten it evenly on the probe. After this stage, the intestinal wall is dissected strictly along the mesenteric edge with an electric knife and the intestinal mucosa is further treated with a swab moistened with boric acid. In this case, a section of the intestine with a length of 8-10 cm is not dissected for the formation of a cutaneous stoma with a urine retention mechanism (FIGS. 2 and 3). The orientation of the graft in the abdominal cavity is changed by 180 ° by rotating the graft around the mesentery so that the undetubularized fragment of the graft takes an aperistaltic position with respect to the forming reservoir. Bring together the edges of the detubularized portion of the graft in the middle, using the sutures of the holder and special clamps to evenly match and prevent excessive deformation of the wall, impose a Reverden suture from the intestinal mucosa. At this stage, use the thread PHA 2/0, the seam is single-row (Figures 4 and 5). Compare the edges of the graft in the transverse direction and stitch them using the Reverden suture, but from the peritoneum, while the suture is continued by about 2/3 of the matching edge (Fig.6 and 7). At this stage, anastomosis of the graft with ureters is performed, the anastomoses are located on the back wall of the reservoir. Anastomoses are formed according to the Nesbit method, modeling silicone catheters are inserted into the ureters, which together with the enterocystostomy catheter are discharged through a separate incision in the anterior wall of the graft (Fig. 8). To give the reservoir a spherical shape, the remaining part of the graft is combined in the transverse direction of the formed part of the graft. To prevent misalignment and skewing of the edges, the comparison begins with a fillet weld, after which a single-row curvy seam is applied with an overlap from the peritoneum from the fillet seam outward until the graft wall is fully matched (Figs. 9 and 10). The next step is the formation of a discharge tube with a urine retention mechanism.

For this, the undetubularized part of the graft is narrowed by applying a Lambert suture in the longitudinal direction at a distance of 0.5 cm from each other with Etibond 3/0 thread and additionally cover the first row of sutures with a continuous twisting suture with the same ligature, a 12 Fr silicone catheter is placed in the lumen of the tube ( 11). The formed intestinal tube is removed through a separate incision to the anterior abdominal wall in the right iliac region and is formed as a flat stoma. The ureter catheters and the enterocystostomy catheter are also led through a separate incision to the anterior abdominal wall, in order to prevent the reservoir from moving in the abdominal cavity and possible torsion of the formed tube and ureters with several sutures, the anterior wall of the reservoir is fixed to the peritoneum of the anterior abdominal wall. The abdominal cavity is sutured, leaving two tubular drains in the abdominal cavity.

Justification of the method.

Today, the main task in the treatment of patients with malignant lesions of the pelvic organs is not only the cure for cancer, but also maintaining a high level of quality of life for the patient. Situations resulting in a cystectomy and the impossibility of an orthotopic location of the urinary reservoir are not rare. The gold standard of the 50-80s of the previous century - the Bricker operation does not meet today's requirements. The main criterion for the formation of the urinary reservoir is - the creation of a reservoir of low intraluminal pressure with a urine retention mechanism and the ability of the patient to take care of the reservoir on his own - to empty it in a timely manner, to carry out the sanitation of the reservoir and stoma. Our proposed method meets all these requirements. The creation of the proposed tank is relatively simple in execution, having a shape close to spherical, the tank is quite large, its capacity increases up to 1 year from 150 ml to 300-350 ml at an intraluminal pressure not exceeding 30-40 cm in st. The high efficiency of the formed urine retention mechanism in the reservoir is due to the following:

- low intraluminal pressure in the tank;

- aperistaltic location of the discharge tube;

- narrowing the lumen of the outlet tube.

The location of the stomic opening allows patients to take care of the reservoir on their own.

Example: Patient D., 53 years old, was hospitalized in a surgical clinic in June 2003 with a diagnosis of bladder cancer stage T3N × M1 (solitary metastasis of the lower lobe of the right lung was determined). Prior to admission to the patient’s clinic, systemic chemotherapy was performed according to the MVAC scheme; it was possible to significantly reduce the size of lung metastases, however, no dynamics from the bladder tumor was noted. A comprehensive examination was carried out in the clinic, consisting of a routine laboratory examination, ultrasound of the abdominal cavity, pelvis, an additional transvaginal ultrasound of the bladder and a transurethral ultrasound of the bladder were performed to assess the local spread of the tumor process, and a computer was performed to evaluate the damage to the pelvic lymph nodes and chest organs tomography. An isotopic study of skeleton bones was performed. TUR biopsy of a bladder tumor was performed. According to the results of the studies, the diagnosis was established: transitional cell carcinoma of the bladder T3N × M1G2. Given the prevalence of the tumor process, a decision was made to conduct multi-stage treatment. At the first stage, a radical cystectomy and bilateral ureterocutaneostomy were performed, and a postoperative diagnosis was made: transitional bladder cancer pT3apN0M1G2. 1 month after surgical treatment, a course of systemic chemotherapy was carried out according to the MVAC scheme, and after three months of examination, no new distant metastatic lesions were revealed. The second stage of surgical treatment is performed - lower lobectomy on the right. According to the results of histological examination, tumor formation of metastases of transitional cell carcinoma. Two months after surgery, another course of systemic chemotherapy. In August 2004, a survey was conducted - local recurrence of the disease and distant metastases were not detected. The presence of two tubes from the ureters, periodic leakage of urine along the tubes did not suit the patient, as it significantly limited the patient's vital activity. Therefore, the patient was proposed and performed the third stage of surgical treatment according to the proposed method, including the formation of a heterotopic reservoir and urine retention mechanism. The postoperative period was uneventful, modeling the ureteral catheters were removed on the 12th day, the enterocystostomy catheter was removed on the 16th day. By this time, the patient was already caring for the catheters on her own, flushing them and, if necessary, performing a change in the discharge catheter. Discharged from the hospital on the 28th day, in satisfactory condition. 2 months after the operation, the cutaneous stoma was satisfactorily formed (Fig. 12), and the x-ray picture of the urinary reservoir clearly differentiates the outlet tube and urinary reservoir (Fig. 13). When observing the patient, a gradual increase in the reservoir capacity, independent patient care of the reservoir was noted, after 7 months of observation, the reservoir capacity was 300 ml, while the intraluminal pressure was not more than 40 cm AH and there was no leakage of urine along the stoma at rest. The patient notes episodes of leakage of urine in cases where the interval between catheterizations increased to 5-6 hours or with active physical activity. However, the presence of a reservoir allowed the patient to increase vital activity. Diagram of the formation of holes on the anterior abdominal wall (Fig. 14).

Technical aspects of the formation of this tank worked out on 7 corpses. In practice, they were used in 3 patients, two women and one man. The average age of patients is 62 years (from 55 to 73). All patients underwent surgery for bladder cancer according to the proposed method, underwent a multi-stage treatment regimen. The characteristics of the operated patients are shown in table 1.

At the time of data collection, patients evaluated their condition at three levels: poor, satisfactory, and good. All patients independently take care of the reservoir - they perform catheterization, dressings, day and night only separate episodes of urine leakage along the stoma occur, more often during physical exertion and prolonged non-emptying of the reservoir. Patient M. also independently takes care of the reservoir, but a catheter has to be installed at night, as it lavishes abundantly along the stoma. All patients are adapted to family and social life.

Thus, the proposed method of heterotopic bladder plasty, including the formation of a heterotopic low pressure reservoir and urine retention mechanism, can be recommended for use in patients for whom the creation of an orthotopic urinary reservoir is not possible due to the prevalence of the disease or due to the features of the previous treatment (radiation therapy, organ-sparing operations). The proposed method is relatively simple and reliable, allows you to maintain at a fairly high level the quality of life of patients after radical organ-bearing operations of the bladder and pelvic organs.

List of sources

1. Hinman F. Operational urology. M .: "GEOTAR-MED", 2001.

2. Kogan M.I., Perepechay V.A. Modern diagnosis and surgery of bladder cancer. Rostov-on-Don, 2002.240 s.

3. Pereverzev A.S., Petrov S.B. Bladder tumors. "Fact", Kharkov, 2002, 300 p.

4. Managadze L.G., Lopatkin N.A., Laurent O. B. and others. Operational urology of the classic and innovation. M .: Medicine. 2003. S. 484 -646.

5. Matveev B.P., Figurin K.M., Koryakin O.B. Bladder cancer Moscow. Verdana, 2001.

6. Vasilchenko M. I., Sergienko N. F., Belyaev L. B., Zagarova V. I., Proletarsky A. V. New variants of intestinal bladder plastic surgery in the experiment. Urology. 2001. No. 5, pp. 7-11.

7. Bricker EM. Bladder substitution after pelvic evisceration. Surg Clin North Am. 1950; 30: 1511-1521.

8. Kucera J. Blasenersatz - operationen. Urologische operationslehre. Lieferung 2. 1969; 65-112.

9. Boyd SD, Lieskovsky G, Skinner DG. Kock pouch bladder replacement. Urol Clin North Am. 1991; 1 8: 641-648.

10. Thuroif J.W., Alken P, Riedmiller H, et al. The Mainz pouch (mixed augmentation ileum and cecum) for bladder augmentation and continent diversion. J Urol. 1986; 136: 17-2.

11. Kock NG, Nilson AE, Norlen LS, et al. Urinary diversion via a continent ileal reservoir: clinical results in 12 patients. J Urol. 1982; 128: 469-475.

12. Camey M, LeDuc A. L'enterocystoplastie avec cystoprostatectomie totale pour cancer de la opinie. Ann Urol. 1979; 13: 114-123.

13. Rowland RG, Mitchell ME, Bihrle R, et al. Indiana continent urinary reservoir. J Urol. 1987; 137: 1136-1139.

14. Walsh P. Campbell's urology / Seventh Edition / vol. 3 (1997).

Claims (1)

The method of heterotopic intestinal plasty of the bladder by mobilizing the ileum with the subsequent formation of the urinary reservoir from it, the mechanism of urine diversion and modeling of the cutaneous stoma, characterized in that the ileum is mobilized for the formation of the urinary reservoir for 55-60 cm, retreating 20 cm from the ileocecal angle, an inter-intestinal anastomosis is formed, then a 50 cm portion of the transplant is detubularized, the graft is rotated 180 ° around the mesentery so that the detubularized the second section was located towards the right iliac region, then the detubularized section was first subjected to longitudinal and then transverse reconfiguration, forming a reservoir of low pressure, the ureters anastomose with the reservoir along its posterior wall on modeling catheters using the Nesbit technique, the remaining non-tubularized portion of the graft is narrowed by application Lambert at a distance of 0.5 cm from each other and additionally cover the first row of seams with a continuous twisting seam with the same ligature, after which the mod catheter-releasing catheters and a formed urine drainage tube are removed through 2 separate incisions of the anterior abdominal wall; after stoma formation, the catheter exit site is delimited from the abdominal cavity by several sutures between the anterior wall of the reservoir and the parietal peritoneum of the anterior abdominal wall.

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